Healthcare Provider Details

I. General information

NPI: 1437148509
Provider Name (Legal Business Name): CHEQUITA HILVERSUM O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 04/22/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 STATE ROAD 312
ST AUGUSTINE FL
32086-4241
US

IV. Provider business mailing address

1950 OLD GALLOWS RD
VIENNA VA
22182-3990
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-2021
  • Fax: 904-824-2039
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC-2951
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC2951
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: